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García Nores et al. Plast Aesthet Res 2023;10:33 https://dx.doi.org/10.20517/2347-9264.2022.146 Page 5 of 10

Flap inset
Blondeel et al. have already published excellent guides on aesthetic breast reconstruction based on the
footprint, conus, and skin envelope. Often, for patients with extremes in body mass index, maximizing the
volume harvested results in flap design where the distal portions of the flap may have questionable
perfusion. Wade et al. reported a statistically significant relationship between the incidence of fat necrosis
2
2
[6]
and BMI (kg/m ) as a continuum as well as BMI (kg/m ) > 35 as an independent variable . For these
situations, we strongly recommend careful consideration of flap orientation during inset to bury any
questionable portion of the flap. An oblique or vertical inset permits the area of maximal perfusion on a
medial row perforator to be utilized as the visible skin paddle inset along the inframammary fold. Careful
attention should be given to insetting the healthiest portion of the flap along the “social breast” or cleavage
area, ensuring that any fat necrosis that may develop will form along the lateral and inferior regions of the
breast. Patients tolerate fat necrosis in these areas much better, because it is less likely to cause visible
deformity when wearing a brassiere or clothing. If a buried partial flap loss occurs, it typically evolves into
fat necrosis, which can be more easily managed than a necrotic skin paddle with underlying tissue ischemia.

MANAGEMENT
Indications for intervention/classification
There is currently only one proposed classification system for fat necrosis. Similar to the well-known Baker
grading scale for capsular contracture, the authors based this classification on whether the fat necrosis is
palpable, visible, and/or painful. Not surprisingly, the most severe Type IV (painful) always requires surgical
intervention. Type II (palpable but not visible) was mostly observed (48%), with 17% undergoing biopsy and
35% debridement. For Type III (visible and palpable), 11% underwent biopsy and 89% underwent
debridement .
[29]

Classification systems may be useful in many conditions but should not be considered a definitive guide for
management. Breast cancer patients may be hypersensitive and anxious about any palpable masses or lumps
in their reconstructive breasts due to concern for cancer recurrence. Additionally, our breast surgeons and
non-surgical colleagues (hematology/oncology or radiation oncology) may be less familiar with the
diagnosis and management of fat necrosis, which can lead to concern when a palpable firm nodule or mass
is noted during examination in the postoperative period. Open communication between all providers is
crucial to avoid unnecessary interventions and to provide appropriate reassurances and workup. It is of
utmost importance to educate all multidisciplinary team members in recognizing fat necrosis from other
differential diagnoses, in order to provide timely onset of therapy and avoid unnecessary tests or
interventions. In the study by Haddock et al., the authors reported per single incidence of fat necrosis, 0.69
revisions, 1.22 imaging studies, 0.77 biopsies, and 1.7 additional oncologic office visits . The cost and
[3]
psychological toll on the patient for additional imaging, biopsy and surgery is not trivial and often
overlooked. The majority of management for this issue is conservative and symptom-oriented. If fat
necrosis is only diagnosed via imaging and is asymptomatic, no intervention is indicated. Some of these
patients may need a lower threshold for treatment of areas of fat necrosis to avoid further unnecessary
worry and/or evaluation.

Timing of intervention
Ellis et al. performed a systematic literature review to develop an algorithm for the management of fat
necrosis based on six articles with level 3 evidence. Again, the incidence varied from 12.7%-40.4% in clinical
diagnosis. The authors noted clinical examination to be the most homogenous diagnostic approach for fat
necrosis, identifying it as a palpable lump or mass of any size. Ultrasound should demonstrate a solid mass
with increased echogenicity of the subcutaneous tissues or a simple cyst not consistent with tumor
recurrence, and further investigation should be conducted 12 months post-mastectomy, once flap swelling